General surgery

Question 1

Initial assessment of an upper GI bleed

Answer 1

• Obtain a quick history - AMPLE (Allergies, Medication, PMH, Last ate/drank, Events leading up to addmission)
• Check for previous bleeds, liver status, known ulcers
• Assess for signs of hypovolaemic shock - tacycardia, hypotension, low urine output (catheterise), cool peripheries

Question 2

Presenting symptoms of upper GI bleed

Answer 2

• Haematemesis - (either red blood or coffee ground emesis)
• Melena (black tarry stool)

Question 3

What is haematemesis?

Answer 3

Haematemesis is defined as bloody vomit originating from a site proximal to the distal duodenum. Haematemesis can either be frank (pre-stomach) or coffee gound (post-stomach).

Question 4

What are the two most common causes of an upper GI bleed?

Answer 4

• Ulcer bleed
• Variceal bleed

Question 5

Causes of upper GI bleed

Answer 5

• Oesophageal origin
  
  • Varicies (secondary to portal hpertension)
  • Oesophagitis
  • Mallory-Weiss tear
  • Oesophageal cancer
• Gastric origin
  
  • Peptic/duodenal ulcer (secondary to H.pylori or NSAID use)
  • Gastritis (secondary to NSAID or alcohol use)
  • Angiodysplasia
  • Gastric cancer

Question 6

Upper GI bleed Airway

Answer 6

• Secure patients airway
• Place hypotensive patients head down to aid cerebral perfusion
• Suction may be required to clear blood/vomitus
• Consider NP airway to facilitate suction

Question 7

Upper GI bleed Breathing

Answer 7

• Obtain SpO2
• Give supplemental high flow O2 15L/min (may be helpful for confused, agitated, elderly patients with poor cerebral function)

Question 8

Upper GI bleed Circulation

Answer 8

• Measure BP and heart rate and monitor for signs of shock
• Obtain IV access
  
  • x2 wide-bore cannula (14G)
  • Aggressive fluid resuscitation 1L crystalloid solution STAT
• Send off urgent bloods - FBC (ectent of anaemia and platelets), LFTs (pre-existing liver disease), U&Es ( co-existing AKI, urea rise), clotting/coagulation screen and ABG
• Cross match blood at least 4 units RCC
  
  • O -ve blood should be given if blood is needed before cross match available
• Other considerataions if likely variceal bleed
  
  • Prophylactic antibiotics
  • Terlipressin IV 1mg
• Arrange for a 12 lead ECG and assess

Question 9

What would a significantly high urea with normal creatinine indicate in an UGI bleed?

Answer 9

Severe UGI bleed

Urea is the end metabolic product fo protein hydrolysis. When blood that is rich in haem and other plasma proteins is present in the GI tract, it mimics a heavy protein meal, and urea is produced.

Question 10

For a patient who is actively bleeding how would you to determine whether to give a platelet transfusion or FFP?

Answer 10

• With a platelet count <50 x 10^9/L, offer platelet transfusion
• With aPTT/PT >1.5 greater than normal, offer FFP

Question 11

GI bleed Disability and Exposure

Answer 11

• Consider catheterisatoin for accurate fluid balance
• Assess pateints using Glasgow Blatchford bleeding score (pre-endoscopy) to assess for urgency of UGIE
• Urgent referral to gastroenterology or surgery for upper GI endoscopy

Question 12

The Glasgow Blatchford bleeding score uses the following parameters:

Answer 12

• Haemoglobin <12.9(M), <11.9(F)
• Urea >6.5
• Systolic blood pressure <110mmHg
• Heart rate ≥100bpm
• Presenting with melaena
• Presenting with syncope
• Hepatic disease
• Cardiac failure

Question 13

Specific causes of upper GI bleeding may be suggested by the patient’s symptoms:

Answer 13

• Peptic ulcer: Upper abdominal pain
• Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia
• Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis
• Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, abdominal distention (ascites)
• Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia

Question 14

What can be done to control haemorrhage of oesophageal varicies?

Answer 14

• Thermal coagulation
• Thromin injection with adrenaline or banding
• Baloon tamponade

Question 15

What are the three main disorders encompassed by the term iscahemic bowel disease?

Answer 15

• Acute mesenteric isahcemia
• Chronic mesenteric isachemia (intestinal angina)
• Ischamic colitis

Question 16

Aetiologies of ischaemic bowel disease

Answer 16

• Occulsive disease eg primary atheroscleosis, distal emolism (associated with atrial fibrillation) vasculitis, extrinsic compression
• Non-occlusive disease - septic shock, hypoperfusion

Question 17

Ischemic bowel disease presentation

Answer 17

• Very severe, constant colicky abdominal pain
• Signs of peritonism may only develop in the later stages
• May be post-prandial association in chronic mesenteric ischaemia, much like the exertional component on angina

Question 18

Intestinal ishchaemia investigations

Answer 18

• CT angiogram - allowing localisation and visualisation of any potential occlusive (embolic or thromus) cause
• urgent ABG with lactate analysis (high lactate consistent with ischaemia)

Question 19

Stepwise management of ischaemic bowel disease

Answer 19

1. Active fluid resuscitation and supportive measures
2. Emperical antibiotics
3. Anticoagulation if indicated
4. Urgent angioplasty, embolectomy/thrombectomy or exploratory surgery if severe
5. Bypass surgery recommended in chronic disease

Question 20

Which bacteria is the most common cause of spontaneous bacterial peritonitis?

Answer 20

Escherechia coli (~60%)

Question 21

Spontaneous bacterial peritonitis presentation

Answer 21

Patients are often unwell, feverish and complain of severe abdominal pain

Question 22

Spontaneous bacterial peritonitis diagnosis

Answer 22

• Diagnostic ascitic tap
  
  • cloudy and sometimes blood stained in appearance
  • neutrophil count >250x10^6/L is diagnostic

Question 23

Spontaneous bacterial peritonitis treatment

Answer 23

• Broad spectrum IV antibiotics until sensitvities guide further treatment
• Albumin replacement is also indicated i
• Antibiotic prophylaxis (oral ciprofloxacin) may be indicated in patients with a total protein of less than 15g/L in the ascitic fluid

Question 24

What would an abdominal CT show in ischaemic bowel disease?

Answer 24

Dilated small bowel loops with thickened walls